Alex Mitchell Karen Lord
Paul Symonds
Department of Cancer & Molecular Medicine, Leicester Royal Infirmary Department of Liaison Psychiatry, Leicester General Hospital
Sept2010 Sept2010
NCRS 2010
Validation of the Distress Thermometer using ADL:
What is the relationship between distress and dysfunction?
Contents
1. Strengths & limitations of DT
2. How to establish “clinical significance” simply 3. Link between distress and dysfunction
4. Lessons for DT cut-offs
Clinical Significance
DSMIV and PHQ9 Includes a question on function
1. Strengths & limitations of DT
Strengths => Mainly Acceptability
Limitations => Reliability and Validity
DT vs HADS-T Validity (n=660) Leicester2009
SE SP AUC CUT
DT – 71.9% 78.4% 0.814 cut point >=4
AnxT – 75.7% 73.4% 0.821 cut point >=5
DepT – 77.6% 82.2% 0.855 cut point >=3
AngT – 77.5% 77.6% 0.823 cut point >=2
HelpT - 69.1% 80.8% 0.809 cut point >=3
DT vs DSMIV Depression
SE SP PPV NPV
DT ma (2007) 80.9% 60.2% 32.8% 92.9%
DT LeicesterBW 82.4% 68.6% 28.0% 98.3%
DT LeicesterBSA 100% 59.6% 26.8% 100%
BSA = British South Asian MA = meta-analysis
(Mitchell 2007 JCO)BW= British White
- Please circle the number (0-10) that best describes how much distress you have been experiencing in the past week, including today.
- What phone number would you like us to contact you on if necessary?
Please tick WHICH of the following is a cause of distress:
Practical Problems Spiritual/ Religious Concerns Physical Problems contd…
Childcare Loss of faith Changes in Urination
Housing Relating to God Fevers
Money Loss of meaning or purpose
in life Skin dry/ itchy
Transport Nose dry/ congested
Work/School Physical problems Tingling in hands/ feet
Pain Metallic taste in mouth
Family Problems Nausea Feeling swollen
Dealing with partner Fatigue Sexual
Dealing with children Sleep Hot flushes
Getting around Emotional Problems Bathing/ Dressing
Depression Breathing
Fears Mouth sores Is there anything important you
would like to add to the list?
___________________________
___
___________________________
___
___________________________
___
Nervousness Eating
Sadness Indigestion
Worry Constipation
Anger Diarrhoea
Distress Thermometer
Distress Thermometer
DT contains only two anchors In its most common version.
Distress Thermometer – Pooled Table
Score Ransom 2006 Tuinman
2008 Mitchell
2009 Lord
2010 Hoffman
2004 Gessler
2009 Clover
2009 Jacobsen
2005 Sum Proporti
on
Zero 68 38 61 123 14 27 65 71 467 18.4%
One 72 31 42 68 5 26 39 46 329 12.9%
Two 77 22 35 44 5 18 30 54 285 11.2%
Three 65 37 42 46 8 23 45 46 312 12.3%
Four 51 29 29 30 8 7 21 31 206 8.1%
Five 41 46 62 40 11 13 41 48 302 11.9%
Six 38 32 23 28 2 16 26 31 196 7.7%
Seven 36 21 23 38 2 15 32 16 183 7.2%
Eight 18 12 18 29 6 9 19 15 126 5.0%
Nine 16 5 8 14 3 3 13 9 71 2.8%
Ten 9 4 7 20 4 0 9 13 66 2.6%
Sum 491 277 350 480 68 157 340 380 2543
Proportion 19.3% 10.9% 13.8% 18.9% 2.7% 6.2% 13.4% 14.9%
Distress Thermometer – Pooled
Proportion
18 .4 %
12 .9 %
11.2 %
12 .3 %
8 .1%
11.9 %
5.0 %
2 .8 % 2 .6 %
7.7% 7.2 %
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
20.0%
Zero One Tw o Three Four Five Six Seven Eight Nine Ten
Insignificant Minimal Mild Moderate Severe
50%
Making a cut based on distribution frequency alone Is difficult, or impossible.
British Journal of Cancer (2007) 96, 868 – 874
Making a cut based on distribution frequency alone Is difficult, or impossible also for the HADS
3. Methods – How to Validate an Cut Point?
Establish validity with dysfunction not depression
8%
DT 37%
DepT 23%
AngT 18%
AnxT 47%
4%
7%
1%
1%
9%
3%
0%
2%
4%
15%
3%
2%
Nil 41%
Non-Nil 59%
DT
AnxT AngT
DepT
Distress overlaps with not just distress but anxiety and anger
Sample
We analysed data collected from Leicester Cancer Centre from 2008-2010 involving 531 people approached by a research nurse and two therapeutic radiographers.
We examined distress using the DT and daily function using the question:
“ How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? ”
“Not difficult at all =0; Somewhat Difficult =1; Very
Difficult =2; and Extremely Difficult =3”
18%
DepT 23%
Distress 69%
Dysfunction 76%
0.3%
3% 2%
28% 26% 22%
Of the 293 Non-Nil
Dysfunction
Distress
Virtually no one with
DepT
depression has neither distress nor dysfunction, but many with dysfunction do not have depression
Dysfunction in 531 cancer patients
55.7%
34.3%
7.3%
2.6%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
Unimpaired Mild Moderate Severe
Chart illustrated distribution of dysfunction in unselected cancer patients
Unimpaired by DT Score
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
1 2 3 4 5 6 7 8 9 10 11
Chart illustrated unimpaired function by DT score
Mean DT Scores?
Unimpaired Mild Moderate Severe
Mean DT Score 2.1 4.1 5.9 6.5
Std Deviation 2.54 3.0 2.56 3.59
Sample Size 296 182 39 14
Simplified DT Range* 0-3 4-5 6-7 8-10
DT distribution by Impairment
0 0.02 0.04 0.06 0.08 0.1 0.12 0.14 0.16 0.18
0 1 2 3 4 5 6 7 8 9 10
Distress Thermometer
Typically severely impared Typically mod impared
Typically mildly impared
Typically unimpared
None at all
Based on the mean levels of dysfunction the following anchors are suggested NB: a lower threshold cut of about 3 seems appropriate
Distress Thermometer
Extreme and incapacitating Very Severe and very disabling Moderately Severe and disabling Moderate and quite disabling Moderate and somewhat disabling Mild-Moderate and slight disabling Mild but not particularly disabling Very mild and not disabling Minimal but bearable
Minimal and not problematic None at all
Based on the mean levels of dysfunction and typical verbal descriptions of distress the following anchors are suggested
